Risk-stratified screening and prevention for gastric cancer in low- and intermediate-incidence settings: Challenges and pragmatic approaches

Despite declining age-standardized incidence rates, gastric cancer remains a major global health burden.Population growth and aging are increasing absolute case and death counts, including in low-and intermediate-incidence settings, where population-wide endoscopic screening may be constrained by cost-effectiveness, healthcare capacity, uptake, and heterogeneous risk.National incidence rates may obscure marked differences in individual risk associated with Helicobacter pylori infection, precancerous gastric changes, ethnicity, migration, and other clinical and environmental factors.This narrative review examines risk-stratified gastric cancer prevention and screening in lowand intermediate-incidence settings.We synthesize evidence on epidemiologic transitions, risk determinants, biomarkers, prediction models, artificial intelligence, and multistep pathways while addressing participation, access, equity, quality assurance, and implementation.Risk-stratified and integrated pathways may offer context-adapted alternatives to uniform population-wide endoscopic screening, particularly where population risk and healthcare capacity are heterogeneous.However, direct evidence that these pathways reduce gastric cancer mortality in low-and intermediate-incidence settings remains limited.Such pathways may combine Helicobacter pylori screenand-treat for primary prevention with risk-based endoscopic screening for the detection of premalignant conditions and early neoplasia, supported by clinical risk assessment, noninvasive biomarkers, and existing preventive platforms.Prospective, setting-specific evaluation is needed to establish clinical effectiveness, cost-effectiveness, feasibility, and equity.